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Volume 4, No. 8, August 2006
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Update your standing post partum discharge orders: Tdap in pregnancy / postpartum
ACIP just came out with new provisional recommendations among Pregnant women. The ACIP recommends that Tdap be given routinely in the postpartum period before discharge if 2 or more years have elapsed since the last Td. The reason for these recommendation is that mothers are the source of 32% of pertussis that occurs in infants.
Other recommendations:
- Health Care Workers the ACIP also recommends Tdap if it's been 2 or more years since last Td.
- Adolescents up to 18 ACIP recommends Tdap if it's been 5 or more years since last Td.
- Other adults <65 Tdap is recommended if it's been 10 years since last Td.
OB/GYN CCC Editorial comment
At some point soon it would be worthwhile considering update your standing orders for Tdap before postpartum discharge . The new provisional recommendations for pregnant women and the recommendations for Tdap in adults are at the link below and they will become official when published in CDC's Morbidity and Mortality Weekly Report (MMWR). http://www.cdc.gov/nip/recs/provisional_recs/tdap-preg.pdf
Repeat Cesarean Deliveries Raise Risk of Maternal Morbidity
As the number of repeat cesarean deliveries increases, so does the risk of bowel injury, ICU admission, and other maternal complications,
CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2.
Silver RM, et al Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol. 2006 Jun;107(6):1226-32.
Membrane Sweeping at 41 Weeks Helps Prevent Post-Term Pregnancy
CONCLUSIONS: Membrane sweeping at 41 weeks can substantially reduce the proportion of women with post-term pregnancy.
de Miranda E, et al Membrane sweeping and prevention of post-term pregnancy in low-risk pregnancies: a randomised controlled trial. BJOG. 2006 Apr;113(4):402-8.
Most Stillbirths Worldwide Are Preventable
INTERPRETATION: The numbers of stillbirths are high and there is a dearth of usable data in countries and regions in which most stillbirths occur, with under-reporting being a major challenge. Although our estimates are probably underestimates, they represent a rigorous attempt to measure the numbers of babies dying during the last trimester of pregnancy. Improving stillbirth data is the first step towards making stillbirths count in public-health action.
Stanton C, et al Stillbirth rates: delivering estimates in 190 countries. Lancet. 2006 May 6;367(9521):1487-94
Sudden infant death syndrome and complications in other pregnancies
INTERPRETATION: Women whose infants die from SIDS are more likely to have complications in their other pregnancies. Recurrence of pregnancy complications predisposing to SIDS could partly explain why some women have recurrent SIDS.
Smith GC, et al Sudden infant death syndrome and complications in other pregnancies. Lancet. 2005 Dec 17;366(9503):2107-11.
Gynecology
ACOG Releases HPV Vaccine Recommendations for Ob-Gyns
Washington , DC -- The American College of Obstetricians and Gynecologists (ACOG) today released clinical recommendations for females ages 9 to 26 for the human papillomavirus (HPV) vaccine in advance of their publication in the September 2006 issue of Obstetrics & Gynecology. A new committee opinion offers general information about the vaccine and addresses proper administration, precautions, and contraindications.
"The approval of this vaccine represents a significant development in women's health and the fight against cancer. Obstetrician-gynecologists should be proactive in educating our patients about the vaccine so that as many women as possible are able to take advantage of this medical milestone," said ACOG President Douglas W. Laube, MD, MEd. "We must be prepared both to administer the vaccine and to answer patient and parent questions that will arise," Dr. Laube added.
"Ob-gyns will play a critical role in the vaccine's widespread use in girls and women and we should discuss vaccination with our patients. Additionally, ob-gyns should stress the importance of continued cervical cytology screening regardless of vaccination status," Dr. Laube added.
Despite the protection the vaccine offers, ACOG emphasizes that the recommendations for cervical cytology screening remain unchanged. Pap screening should begin within three years of sexual intercourse (or by age 21) and then annually until age 30. After age 30, most women can continue annual testing or can choose to be tested every two to three years after three consecutive negative Pap tests. While the vaccine protects against HPV types 6, 11, 16, and 18, there are additional HPV strains that can cause cervical cancer. Pap testing can detect abnormal cervical cells caused by other HPV strains not covered by the vaccine.
The HPV vaccine is most effective when administered to girls and women before the onset of sexual activity. While the US Food and Drug Administration has approved the vaccine for girls and women ages 9 to 26, the federal Advisory Committee on Immunization Practices recommends that girls routinely receive the vaccine between the ages of 11 and 12. Although most ob-gyns are not likely to see many girls in this age group, ACOG recommends that teens first visit an ob-gyn between the ages of 13 and 15. This initial reproductive health visit is an ideal time to discuss the benefits of the vaccine and to offer it to teens.
Vaccination is also recommended for women up to age 26, regardless of sexual activity. Ob-gyns are encouraged to talk about the vaccine any time they see a patient within the target population and offer it to those who have not yet received it. However, women who are already sexually active should be counseled that the vaccine may be less effective if there has been prior HPV exposure.
Women who previously have had abnormal cervical cytology, genital warts, or precancerous lesions can be vaccinated. Those with suppressed immune systems also can be vaccinated, although the protection may be less than that of patients with normal immune function. The HPV vaccine is not a treatment for current HPV infection or genital warts. Patients undergoing treatment for HPV-related symptoms (cervical cytology abnormalities, genital warts) should continue with their prescribed medication and therapy.
While the vaccine has not been shown to have a harmful effect on pregnancy, it is not recommended that pregnant women be vaccinated. If a woman discovers she is pregnant during the vaccine schedule, she should delay finishing the series until after she gives birth. Women who are breastfeeding can receive the vaccine.
The recently approved vaccine shows great promise for controlling the spread of the main types of HPV that cause cervical cancer and genital warts. Given in a series of three shots over six months, the vaccine protects against four strains of HPV responsible for 70% of cervical cancers and 90% of genital warts cases. With widespread use, HPV vaccination has the potential to lower the occurrence of cervical cancer in future generations. Worldwide, cervical cancer is the second leading cause of cancer death in women with nearly half a million new cases and 275,000 deaths annually. An increase in routine Pap testing has led to a decrease in new cases and death (9,710 and 3,700 respectively) from cervical cancer in the US, but there is still a significant population of women who are not regularly screened.
OB/GYN CCC Editorial comment
Will widespread human papillomavirus prophylactic vaccination change sexual practices of adolescent and young adult women in America?
Two virus-like particle human papillomavirus (HPV) vaccines have been shown to be nearly 100% effective in preventing type-specific persistent HPV infections and associated type-specific high-grade cervical intraepithelial neoplasia (CIN). Recently, it has been hypothesized that the administration of this vaccine to young girls in the United States might increase sexual promiscuity among adolescent women and/or young adults. Thus, it has been suggested that focused vaccine strategies either based on the risk of CIN or gender might be more rational or cost-effective. However, such strategies are unlikely to completely eradicate the burden of this disease and decrease the cost of cervical cancer screening.
The same misguided rationale above was used during implementation of the hepatitis B vaccine.
The suggestion that widespread vaccination will alter sexual practices is refuted and the rationale for the vaccination of all girls and boys is outlined in the Monk and Wiley Commentary below. Here is part of that commentary:
“Seat belts do not cause reckless driving, tetanus shots do not cause children to seek out rusty nails, and hepatitis B vaccination has not altered sexual practices or increased injection-drug abuse in any population. Preventive measures do not always lead to high-risk behavior. It is naïve to think that abstinence and monogamy will eradicate the morbidity and mortality of cervical cancer as suggested by some conservative organizations. Society needs to emphasize the benefits of HPV vaccination and find ways to increase its adoption and not create ill-founded barriers. Support and approval of HPV vaccination is not synonymous with support and approval of promiscuity rather a cry to rally together to eradicate cervical cancer worldwide.”
Resources:
Committee Opinion #344, "Human Papillomavirus Vaccination," to be published in the September 2006 issue of Obstetrics & Gynecology, also addresses research recommendations, educational outreach, consent, and advocacy concerns.
http://www.acog.com/from_home/publications/press_releases/nr08-08-06.cfm
Monk BJ, Wiley DJ. Will widespread human papillomavirus prophylactic vaccination change sexual practices of adolescent and young adult women in America? Obstet Gynecol. 2006 Aug;108(2):420-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16880314
New Vaccine for Cervical Cancer Virus Raises Access Questions: Vaccine Approved
http://www.medscape.com/viewarticle/541349?src=mp
Other:
Sensitivity of colposcopy in ASCUS / LGSIL improves with more than two biopsy samples
CONCLUSION: Colposcopy with guided biopsy or biopsies detects approximately two thirds of CIN 3+. Although the sensitivity of the procedure does not differ significantly by type of medical training, it is greater when two or more biopsies are taken. LEVEL OF EVIDENCE: II-2.
Gage JC, et al Number of Cervical Biopsies and Sensitivity of Colposcopy. Obstet Gynecol. 2006 Aug;108(2):264-272.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16880294
HPV-Based Triage May Result in Excess Colposcopies in Young Women
Although women 25 years old or younger have a high prevalence of human papillomavirus (HPV) infection and low-grade cytologic abnormalities, high-grade dysplasia in this age group is relatively uncommon, researchers have found.
CONCLUSION: Given the high prevalence of human papillomavirus and low occurrence of high-grade lesions in young women with atypical squamous cells of undetermined significance, a human papillomavirus-based triage strategy will result in the referral of a large number of women for colposcopy and may limit its cost-effectiveness. LEVEL OF EVIDENCE: III.
Wright JD, et al Human papillomavirus triage for young women with atypical squamous cells of undetermined significance. Obstet Gynecol. 2006 Apr;107(4):822-9
Urodynamics-based detrusor overactivity diagnoses may be insufficiently reliable
CONCLUSION: In our group, lower urinary tract diagnoses of stress urinary incontinence from both clinical and urodynamic data demonstrated substantial reliability and interobserver agreement. However, by conventional interpretation of kappa-statistics, reliability of diagnoses of detrusor overactivity or voiding dysfunction was only moderate, and interobserver agreement on these diagnoses was no better than fair. Urodynamic interpretations may not be satisfactorily reproducible for these diagnoses. LEVEL OF EVIDENCE: II-2.
Whiteside JL,Reliability and agreement of urodynamics interpretations in a female pelvic medicine center. Obstet Gynecol. 2006 Aug;108(2):315-23
Pessaries Helpful in Pelvic Organ Prolapse Patients
CONCLUSION: A vaginal pessary is an effective and simple method of alleviating symptoms of pelvic organ prolapse and associated pelvic floor dysfunction. Failure to retain the pessary is associated with increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3.
Fernando RJ, et al Effect of vaginal pessaries on symptoms associated with pelvic organ prolapse. Obstet Gynecol. 2006 Jul;108(1):93-9
SUI during first pregnancy is associated with a high risk of symptoms 12 years later
CONCLUSION: Onset of stress urinary incontinence during first pregnancy or puerperal period carries an increased risk of long-lasting symptoms. LEVEL OF EVIDENCE: II-2
Viktrup L et al Risk of stress urinary incontinence twelve years after the first pregnancy and delivery. Obstet Gynecol. 2006 Aug;108(2):248-54.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=1688029
Uterosacral ligament vaginal vault fixation durable for vaginal repair of apical prolapse
CONCLUSION: Uterosacral ligament vaginal vault fixation seems to be a durable procedure for vaginal repair of enterocele and vaginal vault prolapse. Lower urinary tract, bowel, and sexual function may be maintained or improved. LEVEL OF EVIDENCE: II-3.
Silva WA, et al Uterosacral ligament vault suspension: five-year outcomes. Obstet Gynecol. 2006 Aug;108(2):255-63.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16880293
Primary dysmenorrhea: advances in pathogenesis and management
Primary dysmenorrhea is painful menstrual cramps without any evident pathology to account for them, and it occurs in up to 50% of menstruating females and causes significant disruption in quality of life and absenteeism. Current understanding implicates an excessive or imbalanced amount of prostanoids and possibly eicosanoids released from the endometrium during menstruation. The uterus is induced to contract frequently and dysrhythmically, with increased basal tone and increased active pressure. Uterine hypercontractility, reduced uterine blood flow, and increased peripheral nerve hypersensitivity induce pain. Diagnosis rests on a good history with negative pelvic evaluation findings. Evidence-based data support the efficacy of cyclooxygenase inhibitors, such as ibuprofen, naproxen sodium, and ketoprofen, and estrogen-progestin oral contraceptive pills (OCPs). Cyclooxygenase inhibitors reduce the amount of menstrual prostanoids released, with concomitant reduction in uterine hypercontractility, while OCPs inhibit endometrial development and decrease menstrual prostanoids. An algorithm is provided for a simple approach to the management of primary dysmenorrhea.
Dawood MY. Primary dysmenorrhea: advances in pathogenesis and management. Obstet Gynecol. 2006 Aug;108(2):428-41.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16880317
Primary Care for Lesbians and Bisexual Women
For the most part, lesbians and bisexual women face the same health issues as heterosexual women, but they often have difficulty accessing appropriate care. Physicians can improve care for lesbians and bisexual women by acknowledging the potential barriers to care (e.g., hesitancy of physicians to inquire about sexual orientation and of patients to disclose their sexual behavior) and working to create a therapeutic physician-patient relationship. Taking an inclusive and nonjudgmental history and being aware of the range of health-related behaviors and medicolegal issues pertinent to these patients enables physicians to perform relevant screening tests and make appropriate referrals. Some recommendations, such as those for screening for cervical cancer and intimate partner violence, should not be altered for lesbians and bisexual women. Considerations unique to lesbians and bisexual women concern fertility and medicolegal issues to protect familial relationships during life changes and illness. The risks of suicidal ideation, self-harm, and depression may be higher in lesbians and bisexual women, especially those who are not open about their sexual orientation, are not in satisfying relationships, or lack social support. Because of increased rates of nulliparity, the risks of conditions such as breast and ovarian cancers also may be higher. The comparative rates of alcohol and drug use are controversial. Smoking and obesity rates are higher in lesbians and bisexual women, but there is no evidence of an increased risk of cardiovascular disease. Am Fam Physician 2006;74:279-86, 287-8
http://www.aafp.org/afp/20060715/279.html
Child Health
Emergency Contraception: A Primer for Pediatric Providers
Emergency contraception (EC) is a contraceptive method used safely and successfully by women for more than 30 years to prevent pregnancy. Nurses at all levels are often the first point of contact for a woman who is requesting EC, thus it is particularly important for them to stay abreast of both the facts regarding the use of this product and the current political controversies. It is particularly important for Nurse Practitioners (NPs) working in primary care with adolescents to remain cognizant of the significant barriers that remain for many women of all ages trying to access this important contraceptive tool.
Clements AL, Daley AM. Emergency contraception: a primer for pediatric providers. Pediatr Nurs. 2006 Mar-Apr;32(2):147-53
Role of subthreshold symptoms on major depressive disorder in adolescents
Results indicate that the presence of subthreshhold symptoms increases risk for onset of MDD [major depressive disorder], with disturbances in mood contributing unique variance over and above all of the other symptoms of depression.
The authors found that
* After controlling for gender and history of depression, seven of the nine DSM-III-R symptoms (depressed mood, anhedonia, weight/appetite disturbance, sleep disturbance, motor disturbance, loss of energy/fatigue, worthlessness/guilt, thinking difficulties, and thoughts of death/suicide) contributed significantly to the prediction of MDD when tested in separate models.
* Endorsement of each symptom increased the likelihood of MDD onset over a 1-year interval.
* In a summary model that included all of the significant symptoms identified in the separate models and that controlled for gender, history of depression, and all significant symptoms, sad mood was the only symptom that contributed unique variance to the prediction of MDD onset.
A symptom-level approach to research on adolescent depression may help guide the identification of adolescents at risk by focusing on the endorsement of particular subthreshold symptoms . . . either before or after an episode of depression or subsequent to an episode in the form of residual symptomology. Such an approach may also help clarify some of the underlying causal mechanisms involved in the development of this disorder and have implications for etiologic models of depression.
Georgiades K, Lewinsohn PM, Monroe SM, et al. 2006. Major depressive disorder in adolescence: The role of subthreshold symptoms. Journal of the American Academy of Child and Adolescent Psychology 45(8):936-944.
Chronic Disease and Illness
Antidepressant Discontinuation Syndrome (See Patient Education)
Antidepressant discontinuation syndrome occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks. Typical symptoms of antidepressant discontinuation syndrome include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. These symptoms usually are mild, last one to two weeks, and are rapidly extinguished with reinstitution of antidepressant medication. Antidepressant discontinuation syndrome is more likely with a longer duration of treatment and a shorter half-life of the treatment drug. A high index of suspicion should be maintained for the emergence of discontinuation symptoms, which should prompt close questioning regarding accidental or purposeful self-discontinuation of medication. Before antidepressants are prescribed, patient education should include warnings about the potential problems associated with abrupt discontinuation. Education about this common and likely underrecognized clinical phenomenon will help prevent future episodes and minimize the risk of misdiagnosis. Am Fam Physician 2006;74:449-56, 457
http://www.aafp.org/afp/20060801/449.html
Are laxatives effective for the treatment of symptomatic hemorrhoids in adults?
Evidence-Based Answer
Fiber has a consistent beneficial effect in the treatment of symptomatic hemorrhoids for up to three months' follow-up as measured by overall symptoms and bleeding.
Practice Pointers
Hemorrhoid treatment options include medical management, rubber-band ligation, sclerotherapy, coagulation, and surgical hemorrhoidectomy depending on the type of hemorrhoid and the frequency and severity of symptoms. The goal of first-line medical management is to minimize constipation and associated straining. Clinical practice guidelines recommend the use of fiber despite inconclusive evidence about its effectiveness in improving symptoms.
Alonso-Coello and colleagues reviewed the literature and identified seven randomized controlled trials comparing the effectiveness of fiber versus placebo in adults 23 to 71 years of age with symptomatic hemorrhoids. The trials studied several types of fiber including ispaghula husk, Plantago ovata or psyllium, sterculia, and unprocessed bran for a treatment duration of one to 18 months. Study size ranged between 28 and 92 participants with a mean of 50. Six of the seven trials assessed the degree of improvement of individual symptoms (e.g., bleeding, pain, itching, prolapse) or overall symptoms measured at six weeks' and three months' follow-up. One study examined rubber-band ligation plus fiber versus rubber-band ligation alone for third-degree hemorrhoids (defined as hemorrhoids that prolapse with straining but are reducible) and measured recurrence rate and the need for repeat procedures at 18 months.
The results of five studies reporting overall symptoms were pooled and showed a 53 percent reduction in the risk of persistent symptoms or lack of improvement. Of those taking fiber, 16 to 40 percent did not improve compared with 23 to 61 percent of those taking placebo. The four studies that reported bleeding as an individual outcome found a trend or a significant difference in favor of the fiber group. Pooled analysis of the two studies evaluating pain or discomfort showed a nonsignificant trend in favor of fiber. Likewise, the pooled analysis of three studies showed a nonsignificant difference between fiber and placebo for persistent prolapse. The two studies that evaluated itching did not find a significant difference between the groups. The one study examining rubber-band ligation plus fiber versus rubber-band ligation alone reported that the number of long-term recurrences was fewer overall in the group that received fiber (15 versus 45 percent, respectively) at 18 months' follow-up.
The most common side effects with fiber were gastrointestinal symptoms, typically starting at the study onset, and these generally were not severe enough for participants to discontinue fiber. The rate of side effects varied considerably among studies, with some studies reporting no side effects and others reporting up to a 50 percent incidence of gastrointestinal bloating.
The American Gastroenterological Association recommends adequate water and fiber intake as the mainstay of medical management and suggests that topical steroids and analgesics also may be useful in relieving hemorrhoidal symptoms.1
Source: Alonso-Coello P, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005;(4):CD004649.
Laxatives for Hemorrhoids? Cochrane Briefs - Clinical Question
REFERENCE
1. American Gastroenterological Association medical position statement: diagnosis and treatment of hemorrhoids. Gastroenterology 2004;126:1461-2.
http://www.aafp.org/afp/20060801/cochrane.html#c2
Interventions to Facilitate Smoking Cessation (see Patient Education)
Tobacco use, primarily cigarette smoking, is the leading cause of preventable morbidity and mortality in the United States, and nearly one third of those who try a cigarette become addicted to nicotine. Family physicians, who see most of these patients in their offices every year, have an important opportunity to decrease smoking rates with office-based interventions. The U.S. Public Health Service recommends that primary care physicians use the five A's (Ask, Advise, Assess, Assist, and Arrange) model when treating patients with nicotine addiction. Physicians can improve screening and increase cessation rates by asking patients about tobacco use at every office visit. Behavior modification can improve long-term smoking cessation success; even brief (five minutes or less) advice on smoking cessation during an office visit can increase cessation rates. The effectiveness of nonpharmacologic treatments generally is lower; therefore, pharmacotherapy is recommended for smokers who are willing to attempt cessation, unless medical contraindications exist. The pharmacologic agents approved by the U.S. Food and Drug Administration for treatment of tobacco dependence include bupropion (a non-nicotine therapy) and nicotine replacement therapies in the form of a gum, patch, nasal spray, inhaler, and lozenge. These agents have similar long-term success rates. Am Fam Physician 2006;74:262-71, 276. http://www.aafp.org/afp/20060715/262.html
Exercise and Older Patients: Prescribing Guidelines
A combination of aerobic activity, strength training, and flexibility exercises, plus increased general daily activity can reduce medication dependence and health care costs while maintaining functional independence and improving quality of life in older adults. However, patients often do not benefit fully from exercise prescriptions because they receive vague or inappropriate instructions. Effective exercise prescriptions include recommendations on frequency, intensity, type, time, and progression of exercise that follow disease-specific guidelines. Changes in physical activity require multiple motivational strategies including exercise instruction as well as goal-setting, self-monitoring, and problem-solving education. Helping patients identify emotionally rewarding and physically appropriate activities, contingencies, and social support will increase exercise continuation rates and facilitate desirable health outcomes. Through patient contact and community advocacy, physicians can promote lifestyle patterns that are essential for healthy aging. Am Fam Physician 2006;74:437-44. http://www.aafp.org/afp/20060801/437.html
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
